Proposed Settlement May Expand Medicare Coverage for Important Services

  • In a proposed settlement of a nationwide class-action lawsuit, the Obama administration has agreed to change the decades-old practice of denying Medicare coverage for skilled nursing care or physical therapy unless the patient could be shown to have a likelihood of medical or functional improvement.


    According to a story in the New York Times, “Federal officials agreed to rewrite the Medicare manual to make clear that Medicare coverage of nursing and therapy services does not turn on the presence or absence of an individual’s potential for improvement, but is based on the beneficiary’s need for skilled care.”

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    This agreement is a significant change in Medicare coverage rules. Now, Medicare will pay for such services if they are needed to “maintain the patient’s current condition or prevent or slow further deterioration.” This care may include home health care, skilled nursing home stays and outpatient therapy, so it will affect elders and others with a large range of ailments.


    According to Judith A. Stein, director of the nonprofit Center for Medicare Advocacy  (CMA) and a lawyer for the beneficiaries, the proposed settlement could help people with chronic conditions like Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, stroke, spinal cord injuries and traumatic brain injury. This new ruling should also “provide relief for families and caregivers who often find themselves stretched financially and personally by the need to provide care.”


    Countless people have been frustrated when they could not continue physical therapy or receive skilled nursing care and still be covered by Medicare simply because their condition is not improving. Yet these same individuals need therapy and/or skilled nursing care to maintain the best level of health they can presently have, and to slow deterioration of their condition.


    This change in the Medicare law will be costly for Medicare to begin with, however if these services keep more people out of nursing homes, it’s likely that significant savings can be realized in the long-term. More importantly, this change will increase the chances of a better quality of life for elders and others with disabilities.


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    Pear, R. (2012, October 22) Settlement Eases Rules for Some Medicare Patients. New York Times. Retrieved from

Published On: October 23, 2012